Rethinking ‘quality’ in health care

‘Quality’ is a word we encounter repeatedly in relation to health care and it has become a powerful health policy driver. In the USA, the Institute of Medicine characterises high quality care as that which is safe, effective, patient-centred, timely, efficient, equitable. ¹ In England, the NHS is ‘organising itself around a single definition of quality: care that is effective, safe and provides as positive an experience as possible’ ² enshrined in the NHS Outcomes Framework, as a set of measurable indicators. ³ General practitioners continue to derive about 30% of their income through scoring points in the Quality and Outcomes Framework.

However, there is growing concern about the unintended consequences of pay-for-performance, ‘evidence-based’ quality standards and related data gathering. Critics argue that such approaches threaten the humanity and authentic dialogue that are central to the therapeutic endeavour.^4,5 The Francis Report in England highlighted the dangers of overreliance on targets for achieving quality in a system as complex as the NHS, calling for a ‘fundamental culture change’, with all health care staff striving to place empathy for the predicament of patients at the forefront of their minds. ⁶ This envisaged culture should, according to Francis, be characterised by openness, transparency and candour. ⁶ The suggestion of a shift towards a system which is appreciated for its shared professional values rather than for assiduous pursuit of targets is welcome, but doubts have been voiced about how this might be implemented; ‘putting patients first’ is hardly a new idea. ⁷

A recent colloquium ‘The Many Meanings of “Quality” in Healthcare: Interdisciplinary Perspectives’ brought together health professionals, academics and patient representatives to unpack the notion of ‘quality’. ⁸ We considered questions such as: Are we confident that there is a desirable match between quality metrics and the properties we seek to enhance? What are the trade-offs in privileging one account of quality over another? What are the professional and patient values that underpin quality? How do we reconcile different ideological perspectives about quality?

Four key interrelated themes emerged. The first was that the delivery of high quality health care depends on a ‘care’-ful act of holding in the balance a range of (sometimes contradictory) perspectives on what constitutes quality. We present some examples as a series of dyads: biometric assessment versus affective engagement; measurement versus description; scientific evidence versus imagination; treating the person as the ‘end’ versus treating the person as the ‘means’; knowing versus not knowing; universal generalisation versus local experience; trust in ‘practice’ versus confidence in ‘the system’. These are not mutually exclusive dichotomies but they are tensions, and clinicians need to work creatively and flexibly to embrace them. Every act of health care is an opportunity for unique tailoring rather than a ‘one-size-fits-all’ prescription and it is this response to the complexity of each individual situation that marks out high quality care from mediocre care, or worse still, poor care. Organisations must offer both the stability required to foster relationships of professional trust and the flexibility to support this responsive creative work.

Secondly, there was a call for more description and less measurement in evaluating quality. Overemphasis on measurement of those aspects of care which are easily measured is not only unreliable but ‘marks the growing ascendancy of the body as object over the body as subject’ (Dr Iona Heath, page 19). ⁸ Systems of external accountability, regulation and performance management may be necessary but run the risk of unintended consequences, generating new work and new risks in busy environments where staff are already overstretched. Proxy measures of quality may offer a standardised, reassuring appearance of quality whilst also crowding out professionals’ capacity to deliver altruistic care, which is less visible and – to all intents and purposes – unmeasurable. Researchers pointed to the value of ethnographic and narrative modes of enquiry, where detailed critical exploration of care practices brings insights into meanings of ‘quality’ that lie beyond the reach of quantification. Patient representatives suggested that personal testimonies provide a better window into subjective experiences of chronic diseases and addiction, and the key to authentic engagement between practitioner and patient.

This ‘authenticity’ of engagement with patients is demanding, challenging work, difficult to sustain in practice. Practitioners need opportunities to discuss and reflect on their experiences and concerns with their peers – the focus of the third theme. This is only possible if organisations value such activities as legitimate forms of work and offer the necessary resources to support them. Such collaborative efforts within health care teams are fertile ground for local, innovative and creative approaches to delivering excellence in particular contexts of care. Unfortunately, the opportunity for such activity is too often marginalised by the demands of externally mandated programmes badged as quality initiatives but experienced as bureaucratic exercises which fail to acknowledge the complexities of delivering care in its social context and the intricate professional judgements this entails.

Finally, the centrality of trusting relationships was highlighted. Trust was identified as fragile, negotiated and emerging from social practices, and not – as is often assumed – a ‘thing’. Trust is something we ‘do’ in relationship with others, and is as crucial to the success of professional teams as it is to professional–patient relationships. Furthermore, it not only involves patients trusting their doctors but also doctors trusting their patients and being willing to manage the inherent uncertainties that this entails. Challenging us to consider that genuine patient-centred care may yet be ‘the most disruptive innovation in healthcare’, ⁸ Jocelyn Cornwell pointed to the potential value of trusting patients in initiatives such as experience-based co-design, where patients identify things that really matter to them as part of an organisation’s approach to quality improvement.

So how do these themes speak to Francis’s call for cultural change in the NHS? We have certainly identified a mismatch between the many and contested meanings of ‘quality’ in health care, and the more limited range of meanings captured by systems of standardisation and quantification. An important paradox is at play; the act of pursuing ‘quality initiatives’ can change practice in ways which may be detrimental to the quality of care. Even the most sophisticated array of metrics captures neither the intimacy of the clinician–patient relationship nor the complexity of the NHS. It is well recognised that complex systems are characterised by unpredictability and paradox, and that the interconnectedness of agents’ actions makes for shifting contexts which can never be fully ‘known’. ⁹ We must also acknowledge that organisational culture is not simply an entity that can be grasped and managed but emerges from the ongoing interactions of its members. ¹⁰ The danger is that culture becomes the new catch-all buzz word, serving to ‘mop up the messy stuff which forever seems to escape various attempts at organisational innovation.’ ¹⁰ As such, top-down efforts to improve organisational culture are likely to meet with many of the same challenges as top-down efforts to achieve quality – that is shaping and influencing local cultures whilst at the same time ushering in a range of unintended consequences.